New evidence suggests that episiotomy, a surgical incision made in the vaginal wall during childbirth, significantly increases the likelihood of postpartum hemorrhage (PPH) among women living with moderate to severe anemia.
Findings published in The Lancet Global Health show that anemic women who underwent episiotomy during delivery were twice as likely to experience severe bleeding after birth compared to those who did not have the procedure.
The conclusions are drawn from the WOMAN-2 Trial, a large multi-country study conducted between 2019 and 2023 involving more than 15,000 women. Over one in four participants underwent episiotomy during childbirth, a procedure in which the tissue between the vagina and anus is surgically cut to widen the birth canal.
Coordinated by the London School of Hygiene & Tropical Medicine (LSHTM) in collaboration with research centers in Nigeria, Pakistan, Tanzania, and Zambia, the study is the first to specifically examine the relationship between episiotomy and postpartum hemorrhage in women with anemia.
Although the World Health Organization advises against routine episiotomy in non-instrumental deliveries, citing evidence that the risks outweigh potential benefits, the practice remains common in many settings. Researchers found that nearly 40 percent of PPH cases among women who had an episiotomy were linked to severe tearing, a rate twice as high as among women who delivered without the incision.
Anemia already places pregnant women at heightened risk, as they tend to develop PPH more rapidly after birth and have fewer treatment options once bleeding occurs. Globally, excessive bleeding following childbirth accounts for an estimated 70,000 maternal deaths each year, with the vast majority occurring in sub-Saharan Africa and South Asia.
According to the researchers, the findings highlight episiotomy as an added and avoidable risk factor for life-threatening hemorrhage in anemic women, one that should prompt urgent re-evaluation of routine childbirth practices.
Dr. Judith Lieber, research fellow at LSHTM and lead author of the study, noted that women with anemia are already disproportionately vulnerable to adverse outcomes during childbirth.
“Women with anemia cannot afford to lose additional blood,” she said. “Our findings show that procedures like episiotomy, which further increase bleeding risk, should only be used when absolutely necessary for the safety of the mother or baby.”
The study also revealed striking differences in episiotomy rates among first-time mothers across countries. In Pakistan, 81 percent of primiparous women in the trial received an episiotomy, compared to 63 percent in Nigeria. Rates were significantly lower in Zambia (29 percent) and Tanzania (15 percent). Women who had previously given birth were far less likely to undergo the procedure.
Globally, episiotomy rates vary widely. In 2022, the procedure was performed in about 9 percent of first-time births in France and 10 percent in Sweden, while the rate in the United Kingdom stood at 20 percent in 2023.
Experts attribute the continued routine use of episiotomy in some countries to outdated clinical training, misconceptions that it prevents severe tearing, beliefs that it speeds up labor, and limited awareness of updated evidence-based guidelines.
Professor Rizwana Chaudhri, a consultant obstetrician and gynecologist and lead investigator for the WOMAN-2 Trial in Pakistan, emphasized the significance of the findings.
“Despite clear evidence that routine episiotomy does not prevent serious tears, the practice remains entrenched in many health systems,” she said. “This is the first study to examine its impact specifically in women with anemia, and such evidence is crucial to driving policy and practice change.”
Researchers involved in the trial are now calling for stronger anemia prevention strategies, including routine screening before and during pregnancy, improved treatment protocols, and broader public health efforts to address the underlying causes of anemia among women of reproductive age.
Story originally written by London School of Hygiene & Tropical Medicine
edited by Lisa Lock, reviewed by Robert Egan
